RCGP News Jun09:RCGP 21/05/2009 17:08 Page 1
News
RCGP launches national audit of cancer diagnosis The RCGP is joining forces with the University of Durham to launch a national audit of cancer diagnosis in general practice The announcement follows a seminar at the College, co-chaired by RCGP Chairman Professor Steve Field and National Cancer Director Professor Mike Richards, to initiate an important piece of work aimed at improving outcomes for patients with cancer. An important partnership has now been set up between the RCGP, the Department of Health, academic departments of universities and leading cancer charities to produce a dedicated cancer strategy for primary care which will be launched later this year. A significant part of this work will be an audit template to help build up a national picture of cancer diagnosis in primary care. Led by Professor Greg Rubin, Professor of Primary Care and General Practice at Durham University, it has been developed and trialled by primary care cancer leads and academic GPs who are researching issues of early diagnosis. Unlike previous audits, it will not be restricted to specific cancers or geographical areas and will have a wider focus than the rapid referral process. GPs will be encouraged to use the Cancer Diagnosis Audit Tool by making available the patient data they collect. Participation is voluntary and all data will be suitably anonymised but the RCGP hopes that as many GPs as possible will engage as results from the audit will be a major contributor in the development of the primary care cancer strategy. The template has been designed to be as user-friendly as possible and participating GPs will be guided and supported throughout the process.
The questions include : ● When did the patient first present? ● How many times did the patient present before referral and what was the main presenting symptom? ● Which investigations were ordered and would rapid investigations would have altered management of the case? ● To which specialty was the referral made? Professor Rubin said: “The way in GPs propose to use the template could have important effects on the meaningfulness of the results and on building up the national picture. Because of this, we are asking GPs to outline the way in which they propose to utilise it, and to be guided by us on appropriate sampling approaches. “Members of the development group have had practical experience of using this audit in their own localities and, with the National Cancer Action Team, will seek to support cancer leads and networks that express interest in its use. We will also provide instructions on its completion and advice on how to formulate a LES to fund this as a service development activity.” The audit template is part of a programme of work on interventions in primary care being led by Professor Rubin on behalf of the College. A standardised template to help GPs analyse significant event audits for cancer diagnosis will be launched in tandem with the audit template. A baseline assessment of the interval from first presentation to diagnosis using the General Practice Research Database is also underway. RCGP Chairman Professor Steve Field said:
When Nancy met Barack...
“There is no doubt that the outcomes for patients with cancer in the UK are not as good as in many European countries. Late diagnosis by GPs has been claimed by some to be the problem but I don’t believe that this is the case. There are problems that start with the patient not presenting for help or screening at their GP surgery right through to delays in access to diagnostics and treatment in secondary care. “This work is an opportunity for us to build up a comprehensive national picture of cancer diagnosis in general practice, to learn lessons and to work with our patients, GPs and primary healthcare teams to improve outcomes for people with cancer. “I am delighted that Professor Greg Rubin is leading this work on behalf of the College and that Professor Mike Richards – the National Cancer Director - has committed himself to this critically important initiative.” ■ For more details, contact Professor Greg Rubin on 0191 -334 0031; e-mail g.p.rubin@durham.ac.uk www.dur.ac.uk/school.health/ centres/erdu/cancer_audit/
THE NEWSPAPER OF THE ROYAL COLLEGE OF GENERAL PRACTITIONERS
JUNE 2009
Inside this issue... E-valuate your learning Essential Knowledge Update is yours for the taking
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Research and Relevance Professor Helen Lester on quality in patient care
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Green Futures How the RCGP is moving forward on sustainability
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Focus on arthritis Clinical Updates on rheumatoid and osteo
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Pharmacogenetics – the new buzzword What it means for primary care
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Homeless but not hopeless One RCGP Fellow’s campaign to reverse health inequalities
Enterprising GPs
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Who gets your vote?
Annual National Primary Care Conference 2009
Excellence in Practice Winning ways for primary care
5-7 November Scottish Exhibition & Conference Centre, Glasgow
ady Get froer !
ARE YOU READY FOR REVALIDATION?
n idatio l a v e R
Don’t miss the opportunity to attend this year’s conference and learn more about the College’s role in Revalidation, the development and delivery of the system, as well as key timelines and requirements. The keynote address by RCGP Chairman, Professor Steve Field, 'Excellence through Revalidation' will highlight how Revalidation requires a commitment by all to improve the quality of care for our patients. Delegates will also learn about enhanced appraisal - what it means for GPs, what is required of GPs and support available from your PCT.
Register now and save ££££’s by booking before 27 July 2009
YES, SHE DID... RCGP clinical guideline expert Nancy Turnbull had the hottest ticket in town when she met US President Barack Obama and his wife Michelle during their recent visit to London. Nancy – who recently retired as Chief Executive of the National Collaborating Centre for Primar y Care (NCC-PC) – and her husband Richard were invited to be part of the historic event as their son had worked on the presidential campaign. Said Nancy: “I was ver y active in registering American voters in London but our son joined the campaign when Mr Obama was ver y much the underdog and he now works in the Obama administration.”
For further details or to register please visit www.rcgpannualconference.org.uk or contact conference organisers, Profile Productions Ltd, on 020 8832 7311 or email: rcgp@profileproductions.co.uk Principal sponsor
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RCGP News Jun09:RCGP 21/05/2009 17:08 Page 2
COLLEGE NEWS
Have you been Updated? H1N1 flu: GPs praised for keeping calm and carrying on
The RCGP's new Essential Knowledge Update (EKU) is a structured learning activity enabling GPs to assimilate and apply new and changing knowledge, relevant to their clinical practice. The EKU is a key element of the RCGP's provision of CPD and to support revalidation. The Updates focus on new and changing information that relates to key clinical areas of national significance (eg, newly published NICE/ SIGN guidelines that are central to GP everyday practice, newly published Gold Standards, new relevant legislation) where there is a dependable consensus about best clinical practice. Each EKU item is hyperlinked to the original source document and summarises the key information. Then it suggests ways that you can reflect on and compare your own practice against the standards and best practice described. It gives you practical tips that the busy GP may want to remember. A clinical scenario follows to allow you to demonstrate that you have assimilated, or already knew the information in the Update item. Lastly it challenges you to capture any learning or service needs in your personal development plan – and guides you to further reading if you want to know more. EKU enables GPs to meet previously identified and unrealised learning needs in relation to new and changing knowledge and information relevant to general practice. It can also be a key element of a GP’s annual CPD folder that can be self-accredited or accredited by peer review within the terms and conditions of the managed RCGP CPD scheme and also contribute, in due course, as part of the managed CPD scheme, to the provision of evidence of a GP’s learning and application in their personal portfolio for recertification purposes. Accompanying each Update is an optional Essential Knowledge Challenge (EKC) – an online assessment to test the GP’s understanding of the Update. GPs will be able to download a certificate for their appraisal folder or ePortfolio, upon successful completion of the Challenge. With all GPs needing to record their educa-
RCGP Chairman Professor Steve Field has praised the efforts of GPs and College staff in reacting to the H1N1 outbreak.
tional activity for CPD, appraisal and revalidation purposes, the RCGP has provided its members with this tool free of charge, as part of their membership benefits package. Non-RCGP members can subscribe to EKU/EKC for an annual subscription of £79. ■ For full details, subscribe or sample EKU, visit www.rcgp.org.uk/eku.
e-GP LATEST New functionality has been added to link the e-learning in e-GP to the RCGP ePortfolio for GP Specialty Training. e-GP is the free online learning resource for NHS GPs and doctors undertaking specialty training for UK general practice. Every time a GP specialty trainee completes an e-GP session, the details of that session will appear as a new entry in their Learning Log. The name of the session and the appropriate curriculum statement will be completed automatically, but the rest of the log entry will be blank to enable the trainee to reflect on the learning achieved in their own time before sharing this learning with their Educational Supervisor. ■ To find out more, visit www.e-GP.org or e-mail e-gp@rcgp.org.uk
Dr Lindsay Henderson MBE FRCGP
Dr Henderson’s career had a major impact on general practice at a local and national level. He joined the RCGP in 1953 and soon after moved to Grantown in Scotland, establishing the Grantown Medical Practice in the early 1970s. He was one of the earliest trainers of GPs and an examiner for many years. In 1979 he was recognised with an MBE and became a Fellow of the RCGP in the same year. Dr Henderson studied at Edinburgh Medical School, where he met his wife Janet – also a GP and member of the RCGP – during an air raid drill in 1941. The couple were in general practice in Grantown from 1955 to 1986 and were well respected throughout the community. He won an award for bravery in 1977 after negotiating with a gunman holed up in a church hall. For this he was awarded a certificate by the trustees of the Sir James Duncan Medal Trust for ‘gallantry and devotion to civic duty’. His friends, family and colleagues have praised his clinical skills and loyalty to his community and general practice as a profession. His colleague Dr Frances Burns said: “Lindsay was an excellent clinician, and it was not just those who trained in the practice who learned from him – his GP colleagues and partners did too and we had fun working with him.” Dr Henderson is survived by Janet and his three children.
RCGP News invites your comments or letters... Please write to: The Editor, RCGP News Royal College of General Practitioners 14 Princes Gate, Hyde Park London SW7 1PU email: rcgpnews@rcgp.org.uk
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Picture courtesy of The Press & Journal
Dr Lindsay Henderson, one of the founding members of the RCGP in Scotland, has died at the age of 85. He was vice chairman of the North of Scotland Faculty from 1974-75, and Chairman and Provost from 1975-78.
ISSN 1755-7720 © Royal College of General Practitioners. All rights reserved. Published monthly by the Royal College of General Practitioners 14 Princes Gate, London SW7 1PU email: rcgpnews@rcgp.org.uk website: www.rcgp.org.uk
“It’s been an intense few weeks for us in general practice but I’m thrilled at how we’ve pulled through,” said Professor Field. He acknowledged RCGP Honorary Secretary Maureen Baker for leading the College’s preparations and liaising with health authorities and external agencies. He also praised the Chairs of RCGP Scotland, Wales and Northern Ireland for their work and keeping the College up to date with specific activities in their countries. The College’s major role was to coordinate communications between the health authorities and GPs – even those who aren’t members of the RCGP. Daily updates were sent to members and regular teleconferences held with RCGP representatives across the UK. One of the first steps taken was to create a dedicated email address (flu@rcgp.org.uk) to take queries from members, which were then
collated and passed onto the Department of Health and Health Protection Authority. Earlier this year the RCGP produced pandemic planning guidelines for GP practices, developed in conjunction with the BMA and Department of Health. Practices are strongly encouraged to read them online at www.rcgp.org.uk. The guidelines contain checklists and practical advice on how to prepare. On the frontline in the first week was RCGP Vice Chair Dr Clare Gerada, who was called in to help when Alleyn’s school in London was hit by an outbreak. “GPs performed incredibly well under huge pressure,” she says. “We dealt with 700 anxious families, answered hundreds of calls and worked with health authorities to update their advice. All of this on a bank holiday, too. “Thankfully the RCGP has prepared as well with fantastic briefings and FAQs which really helped when swabbing patients.” As well as keeping a close eye on developments, the RCGP is undertaking an internal review to analyse how the outbreak was handled and prepare for potential emergencies in future.
Egypt calls for examiners The MRCGP [International] Board is seeking two Examination Development Assessors (EDAs) to support the Egyptian Board of Medicine (BoM) on behalf of the Egyptian Ministry of Health and Population (MoH&P) to develop an examination that will become a conjoint examination of the Egyptian Board of Medicine and the Egypt MRCGP[INT]. This will become the licensing examination for Family Doctors in Egypt. The role is to provide independent Quality Assessment on all aspects of the exam which forms Egypt MRCGP[INT]. ● To be familiar with the framework of the MRCGP International, the contents of the MRCGP[INT] workbook and the methodologies of assessment recognised by the RCGP. ● The EDAs will visit Egypt to assess all aspects of the examination, taking into account the Academic Framework and Quality Assurance Standards as detailed in the workbook. ● The EDAs will normally be accompanied by the Egypt MRCGP International Development Advisor/Advisors (IDAs), whose role is to facilitate the visit, but not to contribute to the final report.
● To provide a Recommendation Report to the MRCGP[INT] Board. ● To revisit in the case of a negative recommendation by arrangement. Person Specification: ● A current MRCGP or MRCGP[INT] examiner, or within two years of retirement, or equivalent examiner in a UK academic department of General Practice (Essential) ● One EDA must be fluent in Arabic (Essential) ● Previous experience of working in the region (Desirable) ● Examiner experience of Quality Assurance Assessment at a Higher Professional Education level (Desirable) ■ To apply, please submit an up-to-date CV with a brief description outlining how you meet the requirements of the role (250 words max) to the International Department of the RCGP by 5pm on 12 June 2009. Interviews will be held on Friday 10 July 2009. Please email all applications to: Andrey Gladkov, International Examination Officer: agladkov@rcgp.org.uk
Maintaining the Gold Standards in palliative care Professor Keri Thomas, the RCGP Clinical Champion for Palliative and End of Life Care, is encouraging RCGP members and anyone working or interested in palliative care to sign up for the fifth national annual Gold Standards Framework (GSF) fifth National Annual Conference in Birmingham on 30 June 2009. Speakers include Professor Mike Richards, National Director for Cancer and End of Life Care, Department of Health; Dr David Colin Thomé, National Director for Primary Care, Department of Health; and Karen Taylor, Director of health value for money studies, National Audit Office ■ For further information please visit www.rcgp.org.uk/circ or email circ@rcgp.org.uk
LAST CALL: June deadline for research funding The RCGP Scientific Foundation Board has announced an increase in its grant awards from £10,000 to the maximum of £20,000 per study. The Board’s objective is to support high quality primary care research studies and increase research skills in general practice. Any GP, primary health care professional or university based researcher can apply for a grant to undertake scientific research in the UK that will be of direct relevance to the care of patients in general practice. The deadline is 30 June 2009. ■ For more information, visit the RCGP Clinical Innovation and Research Centre (CIRC) website www.rcgp.org.uk/circ RCGP NEWS • JUNE 2009
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PROFILE
The best of both worlds Professor Helen Lester is one of the top woman academic GPs in the UK. Here she explains how making the link between academic research and patient care is her driving force
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ENTION QUALITY in primary care – and the name Professor Helen Lester FRCGP will usually feature in the same sentence. As Deputy Director of the renowned National Primary Care Research and Development Centre at the University of Manchester, she is arguably one of the top five women academic GPs in the country. Yet she remains a ‘coalface’ GP at heart, on a personal crusade to demonstrate the relevance of academic research to day-to-day general practice and improving care for patients. Always pragmatic, she says: “Everything I do directly translates back to me and my patients. Research has to make sense and not just to other academics reading about it in a journal. What’s the point of developing a beautiful indicator if it doesn’t work for patients and doctors in the real world? My job is to make sure that things work practically as well as theoretically. “ The first person in her family to go into medicine – and to go to university – Helen says she wanted to be a doctor “for the now deeply unfashionable reason of wanting to make a difference”. She qualified from the Welsh National School of Medicine in 1985, doing most of her junior hospital jobs in and around Cardiff and the Valleys as part of the Cardiff Vocational Training Scheme before becoming a GP in Birmingham for ten years. Married to Huw – a fellow Cardiff medical student and fellow GP – and pregnant with the third of her three children, she embarked on a part-time MD on homelessness which prompted her to pursue a parallel academic career. She joined the Department of Primary Care at the University of Birmingham in 1995. “I was driven by a need to explore some of the questions that every day general practice throws up and also to simply challenge myself. Could I work both as a generalist with my patients and also become expert in a more discrete area of primary care?” Much of Helen’s clinical work and academic research focuses on how to provide quality primary care for people traditionally viewed as members of ‘hard to reach’ groups who generally find it hard to access primary care. Over time, she has developed medical student training modules around homelessness; a questionnaire that measures their attitudes to homelessness and educational packages for GPs around recognising first episode psychosis at an early stage. She also trialled the new role of graduate primary care mental health worker and developed a questionnaire to measure patients’ views of quality primary care mental health care. Her work on GPs’ and service users’ views on quality primary care and how it can be improved for those with a serious mental illness won the RCGP/Boots Research Paper of the Year in 2006 and she was awarded the prestigious RCGP John Fry medal in the same year for her work around primary care mental health.
RCGP NEWS • JUNE 2009
She continues to be heavily involved in mental health research and her current work includes a systematic review and meta-analysis of the value of befriending for people with distress and depression. “This research is absolutely grounded in my reflections from clinical practice around the power of simply sitting and being with patients in distress. What we’ve been able to do is put some evidence behind that observation in terms of an effect size and we now plan to extend the work to see how voluntary sector-led befriending could be developed to work for patients with different needs within an NHS primary care setting.” She took up a personal chair in primary care at Manchester’s NPCRDC in 2006 before becoming deputy director, and she is also Manchester lead of the NIHR School for Primary Care Research. The move to Manchester provided an opportunity for Helen to extend her academic interest in quality in primary care from health inequalities to quality in its broadest sense – and particularly in developing the Quality and Outcomes Framework. She co-led the expert panel group providing academic advice to the QOF negotiators from 2005-09, and was at the helm of a consortium (including the RCGP) recently appointed by NICE to lead the development of new indicators for QOF until 2012, beating off competition from private companies in the process. This will involve piloting all potential new indicators (something that Helen has strongly argued for in the past) as well as advising on thresholds and points. “We intend to apply some science to elements of QOF such as threshold setting and ensure that future indicators make sense to the profession and work across systems and settings before they’re rolled out nationwide.” She also led the successful RCGP pilot on primary care provider accreditation which involved 34 practices and is now set for an England-wide rollout (see sidebar story). “The GPs and practice managers involved did an amazing job and I was particularly pleased that they thought the scheme was valuable and relevant, and that there was no significant difference in achievement between practices of different sizes.” Although her academic work is increasingly
bringing her into contact with the inner sanctum of Government, she is more than happy to deal with the practicalities and leave the politics alone. “As an academic GP, I’m there to provide the evidence base, not to directly influence political decisions. It’s my role to stay neutral, focused and true to the evidence and to prevent unintended consequences as much as I can. “I have to admit it’s a fascinating world and I can see how you could be easily seduced by the aura of power but I’m usually too busy thinking what I’m going to buy from the shops for tea on the way home.” The lack of partnerships for younger doctors is an area of concern, she says. “Salaried positions can work really well for some people but we seem to be suffering from short term-ism and I’m worried that we’re only storing up trouble for the future. Our future leaders of the profession have to be taught and shown by the current generation. “From a feminist point of view, I’m also concerned about how we realise the talents of our incredibly competent women out there and demonstrate that this is a family-friendly profession.” Despite her burgeoning national reputation, Helen’s feet are very firmly planted on the ground – something she attributes jointly to general practice and her family. Ever modest, she says that luck, being in the right place at the right time and having a supportive partner are the major factors in her success. “Being a GP and a mother are both very grounding experiences and it helps that my own mother and my children are distinctly nonplussed by whatever I do. I’m currently gaining a smidgeon of respect from my eldest son but that’s because he’s been offered a place at Imperial if he passes his A-levels and so he’s now reading Pulse!” As for her own work-life balance, she admits: “I’m ashamed to say I don’t do much outside my work and home life. I’m really envious of people who make their own wine or have a parallel sporting career but if the house is quiet and the children are out, I’d probably choose to write something or work on the QOF. “I know it sounds incredibly sad but for me work is a pleasure not a chore. My son always says that if I won the lottery, I’d still go to work and it’s true!”
I do directly translates back to me and my ❛ Everything patients. Research has to make sense and not just to other academics reading about it in a journal. What’s the point of developing a beautiful indicator if it doesn’t work for patients and doctors in the real world?
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Mike Bewick: Will oversee the next-stage development of PMCPA before national roll-out next Spring
Mike takes the lead on accreditation Dr Mike Bewick (above) has been appointed new Clinical Lead of the RCGP Primary Medical Care Provider Accreditation (PMCPA) scheme. Dr Bewick is the Medical Director of the Primary Care Directorate at NHS Cumbria. He joined the Directorate in 2007 and is currently focusing on raising standards in primary care, particularly the national debate around inequalities in healthcare and the development of GP Federations. He previously worked as a full-time GP for over 20 years in Egremont, Cumbria. He has also worked in a number of different roles within the College and is currently Chair of the nMRCGP Assessment Board – a post he has held for the last three years – and Vice Chair of the Postgraduate Training Board. He is keen to see practices engaging with the College’s quality initiatives and will oversee next-stage development of PMCPA ahead of its national rollout in Spring 2010. He succeeds Professor Nigel Sparrow who provided clinical leadership during the pilot of the scheme.
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RCGP News Jun09:RCGP 21/05/2009 17:08 Page 4
NEWS
Facing up to a sustainable future Dr Tim Ballard RCGP Lead on Sustainability THERE IS LITTLE DOUBT that we are facing unprecedented change to our environment and that this is in large part due to human activities. This is worrying enough, but what perhaps is even more worrying is that there seems be a feeling amongst doctors that this is not our core business. There is an unsaid and unwritten assumption that the moral imperative to provide healthcare to our population somehow absolves us from the wider responsibilities that we may have in respect to man made contributions to climate change. The recent edition of the Lancet (373; 9697 pp 1659-1734, May 16-22 2009) gives us the stark warning that climate change is the biggest threat to human health in the 21st century. As Margaret Chan, Director General of the WHO states: “Climate change is the biggest global health threat of the 21st century. We like to think that we practice evidence-based medicine. Well here is the evidence.” The RCGP has embarked on an ambitious programme to address the environmental impact of its own direct activities. We are looking at our day to day activities as well as having our sights set on delivering a new central college building with world class environmental credentials. The challenges to the health of our patients (not to mention ourselves and our families) presented by climate change is colossal. The RCGP has become fully aware of these challenges and we recognise our responsibility to act to influence this important agenda. The impact on health from changing weather systems will come from many directions. There are projections of changing patterns of disease
The future is green: Lord Hunt, Minister for Sustainable Development and Energy Innovation (second left), joined Tim Ballard (far left, David Pencheon and RCGP Chairman Steve Field for the latest RCGP meeting on sustainability such as malaria. Rising temperatures have a direct impact on morbidity and mortality as they had in France in 2003 with an estimated 3,500 extra deaths attributed directly to a rise in seasonal temperatures. There is likely to be a change in disease patterns and prevalence. The most dramatic impacts on health may well come from mankind’s hostile reaction to rapid change with mass migration and resource wars contributing to the burden of ill health. We are aiming to introduce a new chapter in the curriculum and assessment blueprint that reflects the importance of this agenda.
Whichever way I’ve looked at this issue the conclusion that I’ve arrived at is that as GPs we are inextricably linked with both the problems and many of the potential solutions. The NHS is a massive consumer of resources. It is the biggest employer in Europe. It has the potential to greatly decrease the direct carbon impact of its own direct activities. Our own practices can play a key part in these reductions. The RCGP is developing a support package and award to encourage practices to critically review their use of resources and implement change.
Self care: Where do you stand? Professor Nigel Sparrow, Chair of the RCGP Professional Development Board, explores the debate. WHY SHOULD WE encourage self care? What is the right answer for both patients and GPs? Self care has been much in the news of late. One survey says it’s a good thing; another that it’s a waste of time. One source suggests we should all be actively promoting it; another that it’s simply wishful thinking. I would like to take this opportunity to look in more depth at some of these recent findings and see whether we can find a clear path through the maze of information available that gives a clear direction to patients and GPs alike. Let’s look first of all at what self care really means. Is it the management of long-term conditions; is it attending weight management and smoking cessation courses or is it simply about taking simple steps to address our every day health and wellbeing? In 2005 the Department of Health described self care as a wide range of activities undertaken by individuals in relation to their health, defined in policy documents as: “…a part of daily living. It is the care taken by individuals towards their own health and well being, and includes the care extended to their children, family, friends and others in neighbourhoods and local communities.” Others see self care as more focused on the individual management of long-term conditions and might look to the Expert Patient Programme (EPP) for help and guidance in providing selfmanagement skills. EPP has also taken on the self-care resources – Self Care for You and Self Care for Primary Care – developed by the NHS Working in Partnership Programme (WiPP), a programme established to help create capacity in general practice for which I represented the RCGP on the advisory group. Although the programme completed its work in June last year, the resources are still freely available and can be found at www.selfcareconnect.co.uk. Increasingly however, and for the purposes of this article, self care is regarded as not only the steps people take to stay healthy but also how they manage their minor ailments. And this is where the debate really seems to begin.
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The Self Care Continuum Pure self care Individual responsibility
Pure medical care ‘Abdicated’ responsibility
Continuum of self care
Daily SelfMinor choices Lifestyle managed ailments and ailments Assisted prevention management
Chronic conditions Shared care
Acute Compulsory Major conditions psychiatric trauma care
Let’s start by looking at a recent Pulse headline: ‘It’s all very well fantasising about patient self care freeing up GPs to take complex cases off hospitals’ hands – but it just isn’t going to happen in the real world... It’s a fine plan and one most GPs would love to become a reality. It’s just unfortunate that it happens to be a fantasy’. A few weeks later the Pharmaceutical Journal (2009; 282:505) reported that, in a survey undertaken by the Co-operative among 6,000 members, over half of respondents said they would visit a pharmacy for advice relating to a minor ailment before visiting their GP. This figure rose to 60 per cent in the 16 – 44 year age group. Each publication is tailored to its own audience, but it is clear to see where all the confu-
The Health Care Pyramid Tertiary care Secondary care Primary Care
Self care The Department of Health defines the self-care requirements of the population via the Healthcare Pyramid, which suggests that up to 80 per cent of care can be self-care.
General practice is perfectly placed to take the lead role in ensuring that healthcare professionals can effectively inform patients. Any particular example of care lies on a spectrum ranging from 100 per cent self care (eg, brushing teeth regularly) to 100 per cent professional care (eg, neurosurgery). In between these is shared care where individuals or families partner with practitioners including general practice nurses in the care of the individual.
sion begins, especially when we look at another recent story from the Financial Times: ‘If sales of the numerous medicines that can be bought over the counter are anything to go by, then illness at least is recession proof. The value of the UK’s OTC (over the counter) market in 2008 was £2.3bn, an increase of £12m (0.5 per cent) from 2007. Clearly when it comes to minor ailments, we aren’t prepared to economise.’ So we know people are prepared to see their pharmacists; we know they’re prepared to invest in OTC medicines; and yet to date there doesn’t appear to be any evidence to suggest that they are any less likely to consult their GP consultations for a minor ailment. Healthcare Republic recently ran a story on the launch of a new self care movement, Self Care in Practice, a movement supported by a wide variety of health professionals and organisations including the Proprietary Association of Great Britain (PAGB). The thinking is clearly in line with current policy and links closely with the Government’s recent Get Well Soon campaign, encouraging sensible use of antibiotics. One of the problems of implementing self care initiatives is the gap in understanding between patients and health professionals. Recent qualitative research by the PAGB suggests that the two groups simply set different thresholds for when minor ailments should be medicalised. So even when patients self care in the early stages of a cold or cough, all too often they give up after a few days and come and see the doctor anyway. What can we as GPs do to address this? To go back to the original question, why should we encourage self care? My belief is we simply have to persist with self care and with what GP Jim
Practice Based Commissioning has the potential for us to drive through changes in the provision of services for patients that takes account of the environmental impact that these services have. Importantly this needs to take into account the carbon cost of moving both patients and doctors around the system. We need to champion the delivery of high quality services delivered close to our patients homes. It is a difficult area with lots of confounding factors, but that doesn’t mean that we can’t make a big difference. Many of the interventions that we know lead to healthier lives also have a positive impact on the use of scarce resources. This relationship has become known as the co-benefit effect. For example, we know that there is an obesity epidemic in the west. By further encouraging our patients to decrease their food intake and exercise more we can help the individual in the now as well as helping to protect the health of future generations. We are held in high regard by our patients and by society in general. In view of the impact that climate change will have on health burdens alone we have a duty to act now. Following the Doll report on smoking, doctors led the way as exemplars. We need to use our influence both inside the consulting room and in wider society to bring about changes in the behaviour of individuals as well as the attitude of the population as a whole. Everybody, including the politicians, has a GP. The climate and health council is a body set up to try to influence the decision-making of our politicians. We aim to collect 10,000 health care professionals to ‘sign the pledge’. Please make time to look at their website and consider signing. You can do this at: www.climateandhealth. org We are all aware of the concept of probity as described by the GMC document on the duties of a doctor. I believe that we need to develop the idea of environmental probity and not just because of the direct impact on health that climate change will have on us and our children.
Kennedy refers to as the ‘explanation prescription’. In the longer term I believe it is absolutely the only way we can encourage effective and safe self care– and more importantly that our time as GPs, in fact as a whole practice team, is spent delivering an effective service to the patients whose conditions require our skills and expertise. The real key to explanation prescribing is the investment in understanding patients’ personal agendas and ensuring that the whole practice team, including the practice nurse and health care assistant, can play a very real role in helping reveal those. For example, a patient presenting with a cough whose mother had a severe cough for six months and was then diagnosed with lung cancer is anxious because he thinks he is developing a tumour too. As a result it’s worth taking take the time to explain to him what differentiates a normal cough from something more sinister. Writing a quick prescription just because it appears expedient to do so means the underlying issue is never addressed and therefore the real driver is never identified and solved. So we’ve taken a brief trip through the self care minefield but did we manage to find a a clear path? The answer is probably not quite yet. However, I believe the destination is clear even if we’re still now quite sure how to get there. If general practice is to survive then a self care culture has to be firmly embedded within it.
Enabling the self care journey ● Communications around self care should be implemented consistently from central government to PCTs, from GP practices to individual health professional, from health professional to patient ● GPs and practice teams must have adequate assurances that self care initiatives will not lead to serious illnesses going undiagnosed ● The practice team should work together to create a self care culture within the general practice that is understood and supported by everyone ● We must encourage good working relations with our community pharmacy colleagues
RCGP NEWS • JUNE 2009
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CLINICAL UPDATE
Management of RA: What the new NICE Guidelines mean Dr Chris Deighton
Rheumatoid arthritis is the most common chronic inflammatory polyarthritis, affecting about one per cent of the population. A recent report from the King’s Fund highlighted that the provision of high quality care for people with RA across the UK is patchy at best, and non-existent at worst.1 What is high quality care for RA? In February this year, the National Institute of Health and Clinical Excellence (NICE) published the Rheumatoid Arthritis (RA) Management Guidelines. The Guideline Development Group (GDG) was a multidisciplinary team including two GPs, rheumatologists, allied health professionals, orthopaedic surgeons and patients. I was the Clinical Advisor to the GDG, and have worked on these guidelines for the past two and a half years. I therefore feel passionately about them! I believe the recommendations in the guidelines give us an evidence-based approach to improving the quality of care for people with both a recent onset of inflammatory arthritis, as well as those with established disease. In this article I comment briefly on two of the key recommendations that I believe we need to be most aware of. This includes GPs, the hospital-based service and the interface between the two.
for a specialist opinion any person with q Refer suspected persistent synovitis of undetermined ● ● ●
cause. Refer urgently if any of the following apply: The small joints of the hands and feet are affected More than one joint is affected There has been a delay of three months or longer between onset of symptoms and seeking medical advice
Making a diagnosis of an early inflammatory arthritis can be a challenge for all of us, even rheumatologists. A low threshold needs to be exercised for deciding a person may have an inflammatory arthritis, based on symptoms and signs, and certainly not relying on blood tests or x-rays. The key signs are those of inflammation in the joints (synovitis). Although classification criteria for RA exist, these were designed for identifying established disease, and perform poorly in early inflammatory arthritis. Persistent synovitis in any joint dis-
tribution needs specialist assessment. However, this is particularly true for certain patterns, where an urgent referral is called for. Small joint synovitis of the hands and feet carries a poor prognosis which is unlikely to spontaneously remit, and the more joints that are affected, the worse the outcome. As a consultant over the past 16 years, my experience is that the speed of GP referrals has improved substantially, and I see fewer patients these days where I wish they had been sent up earlier. The greater challenge now is getting the message across to the public with appropriate educational campaigns. On the one hand we do not want them taking every ache and pain to their GP, but on the other inflammation, particularly in lots of small joints needs prompt attention. In recent years substantial evidence has lead to support for a ‘window of opportunity’. This concept has much evidence, where a narrow time frame for intervening with disease modifying drugs at the beginning of symptoms may make a huge difference to long-term outcomes. This time period will vary from person to person, but there is evidence to suggest that the first three months of disease are immunologically distinct from established disease, and offer an opportunity for pharmacological intervention that may be subsequently lost. Delays may lead to joint damage that is evident on x-rays that can never be reversed, whereas urgent administration of these drugs can have lasting benefits for patients. Radiological damage inevitably translates into disability for the patient. Time is of the essence in early disease. Although GPs often helpfully perform blood tests to investigate early inflammatory arthritis, these may be completely normal even in the face of aggressive early rheumatoid arthritis, particularly when small joints are affected. The suspicion needs to be clinical. I never mind GP colleagues contacting me with no tests having been done in an early inflammatory arthritis. I would far rather see a patient with no investigations, rather than one in whom waiting for results has lead to a delay in referral, or where results have returned as normal and this has lead to a false sense of security.
people with newly-diagnosed active RA, offer w Ina combination of disease modifying anti-rheumatic drugs (DMARDs) (including methotrexate and at least one other DMARD, plus short-term glucocorticoids) as first-line treatment as soon as possible, ideally within three months of the onset of persistent synovitis. If a person presents with active disease in a symmetrical peripheral distribution (a typical rheumatoid pattern), their prognosis is par-
ticularly poor. Traditionally active RA would be treated with one drug at a time, moving onto another when the first has either run out of steam or proven toxic. Steroids have been approached with understandable suspicion because of the potential side effects. We worked with health economists to determine the most cost effective approach to early active RA. This turned out to be an aggressive approach from the start, with at least two conventional DMARDs, with methotrexate as the anchor drug. Steroids have been included in some form in all published successful combination strategies, but this may be orally, intramuscularly or intra-articularly. The emphasis is on short-term use to gain rapid control of synovitis, and withdrawal before the disadvantages of these drugs outweigh the advantages. In an ideal world, GPs would have access to a specialist service that would see the patient promptly without the need to tide the patient over with some form of steroid. If there are any delays to a patient getting through to a specialist service, my preference is for intramuscular steroids to be used, as oral steroids can obliterate all synovitis, and make clinical assessment difficult at first presentation. The aggressive multiple drug interventions recommended for people with early active RA also argue for this service being provided in specialist care. Other recommendations emphasise the need for regular monthly follow up for early active disease, with a focus on formally measuring disease activity, and responding promptly when this is not satisfactorily controlled. Once the disease is controlled, appointments can be less frequent and at a time and location that is convenient to the patient, where flare-ups are responded to rapidly. There are other recommendations that not only cover acute RA, but also the provision of a high quality service for established disease, with a multidisciplinary service focussed on responding to the needs of the patient (go to www.nice.org.uk/Guidance/CG79 for details), and setting up annual reviews so that the impact of the disease can be formally measured, not only on the musculoskeletal system, but also other silent problems can be identified. For example, in recent years it has become evident that cardiovascular morbidity and mortality is approximately doubled in RA patients compared with the rest of the population, so a heightened vigilance for this is necessary, shared between primary and specialist care. Producing guidelines is one thing, but the challenge now is implementation. I am delighted to say that I have been asked to join a Department of Health Inflammatory Arthritis Commissioning Pathway group. This pathway will be populated with the NICE RA recommendations, bridging primary and secondary care, attempting to speed up the service, and providing an integrated high quality service for our patients. It would be a wasted opportunity for our patients if we did not see these guidelines being fully implemented. I am determined both locally in Derbyshire where I work, and nationally, that these guidelines will be translated into improvements in high quality care for all RA patients 1) See www.rheumatoid.org.uk/ download.php?asset_id=615&link=true for more details. ■ Dr Deighton was Clinical Advisor to the NICE RA Management Guidelines, but the views expressed in this article are his, and not necessarily those of the GDG, NCCCC or NICE.
Helping your patients with osteoarthritis Dr Mark Porcheret GP Research Fellow, Keele University, Director of Keele GP Research Partnership and RCGP Clinical Champion for Musculoskeletal Medicine – Osteoarthritis
Joint pain in older patients (those aged 50 years and over) is most commonly caused by osteoarthritis (OA) and, with an ageing and heavier population, its prevalence is predicted to increase. OA is not just about pain: limited mobility, which in turn can reduce participation in normal dayto-day activities, raises the possibility that ‘adding years to life’ will be accompanied by adding disabled life to years. OA is a common condition managed in primary care, but from recent surveys not very well. About one third of patients aged 65 years and over consulted with a musculoskeletal condition in 2007, with OA the commonest condition they consulted with (the College’s Birmingham Research Unit Prevalence Report for 2007). But in a recent study in the BMJ assessing the quality of care in 13 conditions (Steel et al, 2008), OA scored the lowest for the percentage of quality indicators achieved.
So how can we do better? Firstly it is important to remember that OA is more than a diagnosis made on an x-ray. It is now recognised as a clinical syndrome described in terms of pain and function and a workRCGP NEWS • JUNE 2009
ing diagnosis can be made on three clinical features: q persistent joint pain that is worse with use w aged 45 years and over e morning stiffness lasting no more than half an hour (to differentiate from inflammatory arthritis) There are a few ‘red flags’, such as trauma, infection or neoplasm, which need excluding, but the majority of older patients presenting with knee or hip pain will have OA and don’t need an x-ray to diagnose it. Secondly patients should be treated with a positive attitude – that it is not just ageing and learning to live with it – but that, though not curable, it is treatable and does not inevitably progress.
The recent NICE OA Guidelines recommend three core treatments which should be offered to all patients with OA: ● Written information – for example leaflets from either Arthritis Care or Arthritis Research Campaign (see below) ● Encouragement to exercise, such as walking to improve physical fitness, quadriceps exercises for the knee (there is a very good patient leaflet available – see below) and if further help is needed a referral to a physiotherapist or occupational therapist. ● Advice, if relevant, on weight loss. Although this is a frustrating problem for both GP and patient it can be helpful to explain that joint pain is related to weight, that losing weight can help reduce pain, and then explore simple practical changes they can make to their diet. For pain relief NICE recommends that we should consider the use of paracetamol and/or topical NSAIDs before the use of oral NSAIDs or opioid analgesics. These first line analgesic treatments have been shown to be effective, though won’t be for all, and have fewer side effects than oral NSAIDs or opioids. Remember that your patient will have tried something already so make sure you ask what and reinforce the use of paracetamol or topical NSAIDs. If needed the use of oral NSAIDs and Cox-2 inhibitors should be preceded by a cardiovascular and gastro-intestinal risk assessment. They should be co-prescribed with a proton pump inhibitor and used in the lowest dose for the shortest time period. Long-term use should
be intermittent if possible and use of over the counter NSAIDS should be stopped (see NICE OA Guidelines and the National Prescribing Centre website for further details –7 take the lift to the pain management floor!). There are also a number of other interventions with evidence of efficacy, such as using a walking stick, capsaicin cream, and intra-articular corticosteroid injections. Joint replacement may be needed if there is persisting pain and disability despite non-surgical treatment and referral should be made before there is prolonged and established functional limitation and severe pain (NICE OA Guidelines). So there is plenty we can do to help, and the NICE OA Guidelines list more interventions which can be considered, but always remember that most patients self-manage their condition and that your main role is to support them.
Resources Arthritis Care: www.arthritiscare.org.uk Arthritis Research Campaign: www.arc.org.uk Information on quadriceps exercises: www.arc.org.uk/arthinfo/medpubs/ 6526/6526.asp NICE OA Guidance: www.nice.org.uk/Guidance/CG59 National Prescribing Centre: www.npci.org.uk ■ For further information about RCGP Clinical Priorities and the work of the Clinical Champions, please contact circ@rcgp.org.uk or call 0203 170 8245. ■ The RCGP Clinical Innovation and Research Centre is looking to recruit GPs with an expertise in all clinical, educational and research areas to act as an Expert Resource within the College. To register, please visit www.rcgp.org.uk/clinical_and_research/ circ/expert_resource.aspx or email rwebb@rcgp.org.uk for further information.
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NEWS
Licensing: it’s decision time Pharmacogenetics: What are the implications for primary care?
The GMC is rolling out the next stage of its licensing campaign by writing to all registered doctors across the UK, asking them to confirm whether or not they wish to hold registration with a licence to practise when licensing is introduced. From Autumn 2009 doctors will, by law, need to be both registered and hold a licence in order to practise medicine in the UK. Doctors working overseas will not need a licence for the period they are out of the UK. The annual fee for maintaining registration with a licence to practise will be the same as the current annual retention fee – £410. The annual fee for holding registration without a licence will be £145. GMC Chair Professor Peter Rubin said: “Doctors have an important decision to make in advance of licensing being introduced. They will have the option of holding registration with or without a licence. The decision should be straightforward for most doctors. However, the decision they will make will depend on their pro-
The options available In the licensing campaign, doctors have ONE of three options: Option A: Registered with a licence to practise (£410) All registered doctors will be entitled to a licence. This will legally allow doctors to undertake any of the activities for which UK law currently requires GMC registration.
Option B: Registered without a licence to practise (£145) Those not practising may wish to remain registered without a licence.
Option C: No longer registered (no charge)
Dr Jim Lithgow Education Development Officer (Pharmacy) NHS National Genetics Education and Development Centre Michelle Bishop Education Development Officer (Medicine) NHS National Genetics Education and Development Centre
In reading the popular press and professional literature, pharmacogenetics seems to be the new buzzword. But what does it mean and what are the fessional situation and the particular activities implications for general practice? they carry out. “Legal and contractual issues will require many doctors to hold registration with a licence. However the option to be registered without a licence will provide some doctors, particularly those working outside of the UK, with an alternative.” Licensing will be the first step towards the introduction of revalidation. When this new approach to medical regulation is introduced, doctors with a licence will be subject to revalidation. They will need to undertake the periodic renewal of their licence by demonstrating that they remain up to date and fit to practise. These reforms will help doctors develop their professional practice throughout their careers, and contribute to higher quality of care for patients. The introduction of licensing will begin in Autumn 2009. The GMC will announce the start date shortly and all doctors will know in advance when licensing will begin. Information to help doctors make their decision will be sent to them over the next few weeks. ■ More information can be found on the GMC’s website: www.gmc-uk.org.uk
Changes to child growth charts New UK growth charts are being introduced by the RCPCH using the WHO standard for children from birth to four years. The charts, for the first time, describe optimal rather than average growth and set breastfeeding as the norm. They were constructed using data from healthy breastfed children from around the world who had no known health or environmental constraints to growth. They should be used for all infants however they are fed and for all ethnic groups. The new charts will make weight patterns look different from age six months and it is recommended that all health professionals who use charts should receive some training. The Department of Health recommends that occasional users receive 30 minutes and regular users two hours training. Materials suitable for both experienced staff and students are free to download in both A5 (personal child health record) and A4 format from www.growthcharts.rcpch.ac.uk The new charts are going to look different and the RCPCH wants chart users to familiarise themselves with the changes. The new charts and chart instructions were developed using focus groups of parents and professionals. Though unfamiliar at first, the RCPCH says they should be clearer and easier to use in the long term. The new charts have a separate preterm sec-
tion and clear instructions on gestational correction. A new low birth weight chart will also be available from May for use for any preterm infant below 32 weeks. The charts have no lines between 0 and two weeks. ● Children show highly variable weight loss and gain in the early days after birth, so users are encouraged to assess percentage weight loss rather than plot before two weeks. ● At the age of two weeks, for the first time, the charts allow for slower neonatal weight gain so a drop sustained to two weeks will no longer be normal. ● The 50th percentile is no longer emphasised. ● To help plotting there are centile labels at both ends of each curve and more subtle indicators of the 50th percentile. ● They define when a measurement or growth pattern is outside range of normality and advise when further assessment is advisable. ● All information in the personal child health record is now aimed at parents. The new charts should be used for all babies born in England after 11 May and the existing UK90 growth charts will continue to be used for children over four years and children who are already using them.
Prevention is better than cure… RCGP Chairman Professor Steve Field is a speaker at the Preventive Health 09 Conference organised by govnet.co.uk at the QEII Conference Centre, Westminster, on Thursday 25 June. The conference will look at the increasing role of local care practitioners in the early diagnosis and treatment of illnesses. RCGP Members and Fellows can save £100 and attend for £149 + VAT. Please quote ‘RCGP’ when booking to secure your discount. More details at: www.govnet.co.uk/preventive
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Pharmacogenetics is the use of knowledge of genetic variation to optimise drug therapy. Generally this involves looking at genetic variation in individuals to choose the most appropriate drug and dose to optimise response and avoid adverse reactions. But it is also used to identify genetic variations in cancer or microbial cells in order to identify optimal therapy. While the use of pharmacogenetics is still largely confined to tertiary care, it’s starting to have an impact on clinical practice in primary care. For example, over-the-counter supply of azithromycin for chlamydia is provided only for people who have tested positive to a nucleic acid test for the microorganism. In tertiary care, pharmacogenetics testing is currently being used to optimise drug therapy, as seen by HLA-B*5701 genetic testing to predict abacavir hypersensitivity. Hypersensitive reactions to abacavir, an anti-retroviral drug, occurs in about five per cent of people and a genetic variant, HLA-B*5701, is known to be associated with this reaction. By testing individuals for this genetic variation, clinicians can effectively identify many patients at high risk of an adverse reaction to the
drug. This test is currently recommended for all patients in the UK prior to being prescribed abacavir. Genetic testing, including testing for the gene products, is also required prior to the use of several other licensed drugs including trastuzumab (testing for the presence of HER-2 protein in the tumour cells of women diagnosed with breast cancer) and cetuximab (testing for alterations in the genetic code of K-RAS, as tumour cells that carry an altered form of the Kras protein will not respond to treatment). Pharmacogenetics is also used in the development of drug therapies. Imatinib was first licensed for the treatment of chronic myeloid leukaemia (CML). 95 per cent of people with CML have a chromosomal abnormality in the cancerous cells, characterised by the presence of the abnormal ‘Philadelphia chromosome’. As a consequence of this chromosomal abnormality a fusion protein, called brc-abl, is continually produced leading to excessive cell proliferation. Once the genetic information about these cancer cells was identified, the drug imatinib was developed to inhibit this fusion protein. So why aren’t more pharmacogenetics tests available now? There is a need for evidence of the clinical usefulness of these tests. In most cases where genetic variations may affect the drug regimen, it is still more reliable to base clinical decisions on traditional approaches, such as monitoring of blood levels, as opposed to genetic testing. However, an increasing number of pharmacogenetics tests are being promoted and the challenge for GPs is to identify those that are evidence-based and clinically useful. The NHS National Genetics Education and Development Centre is working with health professionals to identify the education they need to apply pharmacogenetics effectively in their practice. In support of this, the Centre has developed a series of resources, with clinical examples, to raise awareness of the field. These, plus links to publications and e-learning modules, can be found on our website at www.geneticseducation.nhs.uk
Clinical applications of pharmacogenetics Predict the aggressiveness of a cancer
Chlamydia DNA testing and antibiotics in community pharmacy
Gene therapy to treat inherited sight disorder
Development of safer drugs such as Imatinib for leukaemia
PROGNOSIS CHOOSING THE RIGHT DRUG
DIAGNOSIS
GENE & STEM CELL THERAPY
Testing to identify breast cancer patients who will respond to Trastuzumab
Genetic testing to optimise Warfarin dosage
OPTIMISING THE DOSE
PREDICTING ADVERSE DRUG REACTIONS
DRUG DEVELOPMENT PROFILING INFECTION & CANCER Rapid identification of drug-resistant tuberculosis
Predicting potentially lethal hypersensitivity reaction to Abacavir in HIV-AIDS patients
MONITORING PROGRESS Monitoring drug resistance during cancer management
Is your bag up to date? Free AMD materials A new website has been launched enabling GPs to register and maintain the contents of their medical bags online to ensure that they are kept up to date. From £2.99 per month, doctorsbaguk.com enables GPs to manage the contents of their medical bag and receive email reminders when content needs replacing. To support our members, the RCGP recommends this useful website as a way of demonstrating that GPs have a system in place to monitor drugs in their emergency bags. (Refer to Clinical Governance Practice Self Assessment Tools under the ‘Patient Safety’ section; and RCGP Scotland Revalidation Toolkit, Section 3A(4) Drugs, Equipment and Emergency Care). By subscribing to this service, you will have a record of the drugs in your medical bag. This can be printed out as evidence for the medicines management part of the QOF, which requires doctors to keep their medical bags regularly updated and to have a system to check drugs are in date.
for your surgery
GPs who are interested in finding out more about the current Age-related Macular Degeneration television campaign can request a pack including patient leaflets and a surgery poster at www.beamdaware.co.uk The Be AMD Aware campaign is supported by the Royal National Institute of Blind People (RNIB) and aims to encourage people aged 55 or over to familiarise themselves with the symptoms of AMD (blurred vision, distortion of straight lines, blind spots and loss of central vision) and to have regular eye health checks. A recent survey showed that people in the UK are at risk of losing their sight as 44 per cent know nothing about (AMD) – the country’s leading cause of blindness. RCGP NEWS • JUNE 2009
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FOCUS ON HEALTH INEQUALITIES
No place like home..? RCGP Fellow Dr Nigel Hewett feels so passionately about the importance of care for the homeless that he would like to see the creation of a GP subspeciality of Homeless Care. He has been working with homeless people in Leicester for 20 years. Here he explains how the local homeless care service is setting national standards – and changing lives. PRIMARY CARE really is the key to turning around the lives of homeless people. The average life expectancy of a homeless person in Leicester is 40.2 years. GPs are uniquely placed to help make changes to the provision of local care and help to make a real difference to turning around the lives of these people. Ours is the only speciality that can confidently treat problems of physical ill health, mental ill health and substance misuse in the same consultation It’s clear that a multi-disciplinary approach is key to success and that GPs are incredibly important in making it happen. Our team of frontline workers from health, housing and the voluntary sector have been meeting regularly since 1997 to coordinate local services for the homeless. It was out of these meetings that we came to the conclusion that a one-stop shop right in the heart of Leicester was essential and the idea for the Dawn Centre was first conceived. The £3.8milion Dawn Centre includes a 42 bed night shelter run by Leicester City Council, a drop-in centre run by the YMCA and the primary health care centre. Its key aim is to make sure services are as easily accessible as possible. Among the target population are rough sleepers, direct access hostel dwellers, street sex workers and residents from two local bail hostels. In the six consulting rooms the practice team provided 1,090 patients with 10,049 15minute consultations last year – an 18 per cent increase on consultations two years ago before we moved to the new premises. The health team consists of a Consultant Nurse, three more GPs, a Primary Care Drug Worker, Practice Manager, Health Visitor, Practice Nurse, Case Note Summariser, health care coordinator and three reception and administration workers. One of the GPs is also an Associate Specialist in Psychiatry and another leads on all treatment of drug users. Their overall patient satisfaction score was 89.8 and patients use the Dawn Centre as their registered address. As well as directly employed staff, the service also hosts a number of other services. These include daily access to a team of three community psychiatric nurses for homeless patients, a psychologist and visiting psychiatrist, counsellor, aromatherapist, alcohol team worker, midwife, podiatrist and optician.
New support for primary care teams working with asylum seekers with mental health issues Dr Les Ashton GP
Jan Moore Senior Practice Therapist
A new guide, endorsed by the RCGP, is now available to support primary care clinicians in their work with asylum seekers with mental health issues.
Dr Hewett: GPs are uniquely placed to help make a real difference to the homeless Outcomes of multi-agency working with the hardest to help rough sleepers are audited annually. Successes include 60 per cent of clients now placed in a hostel, supported housing or independent tenancy; 58 per cent with mental health issues engaging with health workers; and 35 per cent of patients with alcohol issues began to address their problems, as did 50 per cent of those with substance misuse issues. Another factor in our success is the accommodation available to the people attending the centre. The team at the Dawn Centre tries to offer the best possible care, and we all strive to make a long-term difference to the lives of our patients. On the residential side alone we have 42 bedrooms all with ensuite facilities, some are doubles, some more suited to disabled people, and a couple even have dog kennels. The drop-in centre also offers washing and laundry facilities, as well as providing office and conference facilities. Visiting agencies regularly present workshops and classes for clients on a wide variety of subjects including numeracy and literacy, and work and life skills. There are also computer training sessions in a fully-equipped computer site, which was funded from a legacy. Art classes are held in an activities room, and home economics and cooking sessions in the large teaching kitchen. ■ More information can be found on the work of the Dawn Centre at: www.leicester.gov.uk/dawncentre ■ Dr Hewett is currently working with Professor Aidan Halligan at University College London Hospital on a project to identify and interview homeless people in hospital wards to try to turn around their lives. He is also working with other homeless organisations to identify formerly homeless volunteers for future projects.
● RCGP CHAIRMAN Steve Field recently met Dr Hewett to find out about the Dawn Centre’s work. He said: “Social enterprise is an important way to take forward primary care initiatives which want to turn services around in local areas. I meet a lot of College Members and Fellows running initiatives which work well around the UK and can be replicated by colleagues and I was particularly impressed with the work of Dr Hewett and his colleagues.”
The guide is intended as a practical manual for primary health care staff involved in the development and delivery of mental health care provision to asylum seekers. The document identifies some of the key challenges and approaches that health professionals might consider as part of good clinical practice, specifically when undertaking a mental health assessment. It is divided into four sections, which cover the following areas: ● Definitions and entitlements to health care ● Why asylum seekers mental health needs differ from those of other groups ● Practical issues around the management and delivery of effective services within a primary care setting. ● Issues around staff support and wellbeing The authors’ experience of working with this particular client group over several years highlighted the fact that the mental health needs of this group are multifaceted and complex. Asylum seekers come from many diverse cultures and backgrounds but the common thread that tends to bind them all is that they are fleeing what they consider to be persecution and other atrocities. Many arrive in this country in a traumatised state. Not all will have been subjected to extreme forms of violence and terror, but all will experience disconnection and dislocation from everything that has been familiar, including loss of their home, family, community and status. Most, if not all, will experience sadness, anxiety and depression, with associated poor sleep patterns, problems with poor memory and concentration, disorientation and confusion. In more severe cases asylum seekers may present with Post Traumatic Stress Disorder, and psychotic illness. Similarly, in some cultures, the limitations of language might also result in some expressing psychosomatic symptoms as a means of conveying their psychological distress.
Others may also arrive with poor physical health, sometimes the result of inadequate health care systems in their home country; others may have been denied appropriate medical treatment. Arrival in the UK creates additional pressures in the form of Home Office interviews, asylum refusal, frequent relocation and destitution. Language barriers, mistrust of authority and fears about confidentiality can further hinder the effective delivery of health care of asylum seekers. The exact number of asylum seekers in the UK is unknown, although it is estimated that there are at least 500,000 refused asylum seekers presently in this country. The problem of refused asylum status often results in destitution. The latter has risen sharply over the last few years and often creates further difficulties, not only for the client but also for those who are trying to provide care. Clinicians will also be faced with difficult moral and ethical issues of knowing how to provide health care to refused asylum seekers, especially when asylum health care legislation frequently changes. It is therefore not surprising that for many clinicians, working with this group can be extremely challenging, frustrating, stressful and upsetting. This practical guide has been produced to not only share the learning from the authors experience, working in a specialised primary health care setting, but also to offer suggestions for good clinical practice. Importantly, it also offers helpful advice about how clinicians might take care of themselves in delivering care to this client group. ■ The Guide to Providing Mental Health Care Support to Asylum Seekers in Primary Care is available at: www.rcgp.org.uk/pdf/ corp_Guide_to_providing_MH_ support_%20to_asylum%20seekers.pdf ■ Dr Les Ashton and Jan Moore both work at ASSIST, a specialist primary health care service solely for asylum seekers and refugees in Leicester. They can be contacted at ASSIST, 1a Clyde Street, Leicester LE1 2BG. Telephone 0116 295 2400 or e-mail: L.ashton@gp-y00344.nhs.uk jan.moore@leicspart.nhs.uk
Patients, profit and primary care: the impact of privatisation The RCGP is hosting a major conference on the impact of competition and privatisation on health inequalities next month. The aim of the conference is to help primary care professionals, the RCGP, patient organisations and other interested parties to develop professional responses to the challenges ahead. Issues covered will include the use of monetary incentives (and disincentives); refugee primary care; patient perspectives; pay and conditions; ethical dilemmas in privatisation; and the impact of the RCGP Federated Model. Delegates have a choice of six workshops to attend, and a debate will be held with views from the corporate sector, the RCGP and the primary care work floor. International aspects and the differences between England, Scotland and Wales will also be highlighted.
CONFIRMED SPEAKERS INCLUDE: ● Professor Sir Michael Marmot Chair of the WHO Commission on Determinants of Health ● Dr Iona Heath London GP and Chair of RCGP International ● Dr Rhona McDonald Lancet Senior Editor, who will chair a Chatham House Rules discussion ● Professor Martin Marshall Chair of RCGP Medical Ethics Committee
Patients, profit and primary care – health inequalities, ethics and privatisation
On an upward curve: The Dawn Centre makes sure services are as easily accessible as possible RCGP NEWS • JUNE 2009
Date: Wednesday 15 July 2009 Venue: RCGP, 14 Princes Gate, London SW7 1PU Members: £100 Students/Associates in Training: £25 Non members: £125 To book: Online at www.rcgp.org.uk or email healthinequalities@rcgp.org.uk 7
RCGP News Jun09:RCGP 21/05/2009 17:08 Page 8
AWARDS
GP ENTERPRISE AWARDS 2009: THE FINALISTS
The RCGP has teamed up again with GP newspaper for the popular GP Enterprise Awards. The awards celebrate innovation in general practice and promote ideas which can be easily adopted by most GP surgeries. Snapshots of the award winning entries are outlined here and we are looking for one overall winner. You can cast your vote at www.healthcarerepublic.com/awards and the closing date is Wednesday July 1. Everyone who votes will be entered into a prize draw for an iPod Touch. This year’s sponsor is the Medical Defence Union.
WINNER INNOVATIVE CLINICAL CARE: GENERAL Dr Richard More and Dr Robin Carr Yeovil, Somerset
WINNER RISK MANAGEMENT Dr Nigel Masters High Wycombe, Buckinghamshire
Two GPs were determined to improve COPD care and reduce hospital admissions across their county but realised that the problem required a novel solution. Dr Carr (left below) is a hospital practitioner in respiratory medicine, while Dr More had an interest in organisational change, and they decided that a new structure was needed if they were going to succeed. They set up a limited company, called Avanaula (Greek for breathing space), and by now were both part-time in order to focus on COPD, nationally the cause of one in eight hospital admissions. “We focused on the idea rather than the existing structure and were relentless in pursuing it,” said Dr More. “We needed to identify these patients and stop them becoming unwell.” The GPs decided that they needed a nurse-led organisation and had been impressed by their experience of a home ventilation service. The service is based around a 90-minute nurse assessment with “plenty of opportunity for patient education”.
Winning the GP Enterprise Awards in 2004 might have been enough for some people, but Dr Masters came back this year with another blockbuster idea. He impressed the judges in the Risk Management category with his croup calculator to reduce the risk of drug dosage errors. He saw that dexamethasone was the treatment of choice but difficult to administer by tablet. Then a registrar joined the practice and suggested he use the liquid format, as they do in paediatric units. Dr Masters found that he could not easily calculate the correct dosage according to the child’s weight. So he decided to create his own electronic calculator to do the mathematics for him. A friend produced a basic Excel spreadsheet and the practice refined its workings. The calculator has now been in use at the surgery for over a year, but Dr Masters said it could be especially useful for out-of-hours organisations, paediatric units and A&E.
WINNER PRACTICE TEAM Dr Shikha Pitalia Wigan, Lancashire A brilliantly simple idea helped the team at Ashton Medical Centre overcome a major access issue for their patients. Surgeries were fully booked but there were high DNA rates of up to 20 per cent of appointments on some days. The practice sent the standard letters and telephoned non-attenders but the problem persisted. By interviewing patients, through a forum and patient survey, the GPs found that the telephone lines were too busy for patients to cancel their appointments. The solution they came up with was to give patients a mobile phone number that they could use to text the surgery and cancel an appointment. Dr Pitalia said: “We had thought of installing another telephone line but that would have had implications for staff time in having to run it. But the mobile phone is only used for receiving texts. It’s kept by the appointments computer and checked intermittently. Cancellations are actioned quickly and appointments are freed for other patients.”
WINNER ENTERPRISING USE OF IT Dr Juno Jesuthasan Ipswich, Suffolk
WINNER INNOVATIVE CLINICAL CARE: SPECIFIC Dr Nejla Hussain Wolverhampton, West Midlands Dr Hussain was in training as a GP registrar when she first developed the idea of providing a clinic for carers. “I noticed that patients were coming in with their carers but in the ten minutes that we had, there was only time to focus on the patient and I never had the opportunity to ask the carer how they had been coping.” She researched the topic, presented her plan at a practice meeting, and won the backing of the team. They started identifying carers through Read codes, and Dr Hussain was soon running a monthly clinic of 15-minute appointments. During the consultations she would address any ongoing problems and provide information on the benefits and support available to carers, and respite services such as carer holidays and art therapy groups. “The feedback from these patients has been excellent. Most of my consultations were about stress and depression. Some were about hypertension and fungal infections from repeated washing of the clothes of the person they cared for.”
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Dr Jesuthasan created innovative training videos for his practice team, using software that records the activity on a computer screen. The GP trainer, who is also programme director of Ipswich VTS, part of Eastern Deanery, was frustrated by the lack of uniformity in staff training. “People were not always getting the same training because the trainers were different, or people couldn’t make the meetings, or because they all learn at different speeds. “How do you train people in all the complexities of modern general practice in so little time? I wanted to give everyone a good deal on training – because it’s the key to improvement, to job satisfaction and satisfying the needs of patients.” Dr Jesuthasan found the answer in screen capture software that records what’s happening on your computer and allows you to play it back in high quality video. Now there is a selection of training videos on the practice intranet – some of which are only one minute long – that staff can choose to view at their own pace and when they have time.
WINNER PRIMARY CARE NURSING Ann Francis Health visitor, NHS Luton Taking the time to listen to her patients enabled Luton-based health visitor Ann Francis to improve services for pre-school children with atopic eczema. She learned that local parents did not understand why their children had eczema and required education about environmental factors that affect the condition, plus basic management techniques, including the correct use of emollients. This inspired her to develop a weekly nurse-led clinic, into which pre-school children with eczema could be referred. It involved inviting parents to a 20-minute appointment, held in a children’s centre, and providing simple advice around issues that affect eczema, such as bed-sharing, non-cotton clothing, pets and food allergies. Misconceptions can also be addressed: “Parents have often been prescribed emollients by their child’s GP and believe creams will eradicate the condition completely,” said Ms Francis. “When the condition remains the same, they conclude the creams do not work and return to their doctor.” RCGP NEWS • JUNE 2009